Max P. Rosen

Joint Replacement Surgery in Elderly Patients With Severe Osteoarthritis of the Hip or Knee: Decision Making, Postoperative Recovery, and Clinical Outcomes

BACKGROUND Osteoarthritis (OA) of the hip and knee is a common cause of pain and disability in elderly patients. Joint replacement surgery can alleviate pain and restore function but is associated with risks and discomfort. METHODS We conducted a prospective cohort study to examine decision making and clinical outcomes for elderly patients (age >or=65 years) with severe OA of the hip or knee with symptoms inadequately controlled with conservative treatments. Osteoarthritis symptoms and functional status were assessed at baseline and at 12 months. Postoperative symptoms and function were assessed 6 weeks, 6 months, and 12 months after surgery. RESULTS For the 174 patients studied (mean age, 75 years; 76% were female, 17% were nonwhite, 69% had knee OA, and 31% had hip OA), the mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score was 56 on a 100-point scale. During a 12-month follow-up, 29% had joint replacement surgery. Of patients who had surgery, no patients died, 17% had postoperative complications, and 38% had postoperative pain lasting more than 4 weeks. The median time to recovery of independence in walking was 12 days and to ability to perform household chores was 49 days, with similar times for patients 65 to 74 years old and those 75 years or older. At 12 months, WOMAC scores improved by 24 points in the patients who had surgery and 0.5 point in the patients who did not have surgery (P < .001); improvements were 19 and 0.3 points in patients 75 or older (P < .001). Among patients who did not have surgery, 45% reported that surgery was not offered as a potential treatment option. CONCLUSIONS Elderly patients who had hip or knee replacements for severe OA took several weeks to recover but experienced excellent long-term outcomes. Physicians often do not discuss joint replacement surgery with elderly patients who might benefit.

ACR appropriateness Criteria® right lower quadrant pain - Suspected appendicitis

The most common cause of acute right lower quadrant (RLQ) pain requiring surgery is acute appendicitis (AA). This narratives focus is on imaging procedures in the diagnosis of AA, with consideration of other diseases causing RLQ pain. In general, Computed Tomography (CT) is the most accurate imaging study for evaluating suspected AA and alternative etiologies of RLQ pain. Data favor intravenous contrast use for CT, but the need for enteric contrast when intravenous contrast is used is not strongly favored. Radiation exposure concerns from CT have led to increased investigation in minimizing CT radiation dose while maintaining diagnostic accuracy and in using algorithms with ultrasound as a first imaging examination followed by CT in inconclusive cases. In children, ultrasound is the preferred initial examination, as it is nearly as accurate as CT for the diagnosis of AA in this population and without ionizing radiation exposure. In pregnant women, ultrasound is preferred initially with MRI as a second imaging examination in inconclusive cases, which is the majority.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

ACR appropriateness criteria® pretreatment staging of colorectal cancer

Because virtually all patients with colonic cancer will undergo some form of surgical therapy, the role of preoperative imaging is directed at determining the presence or absence of synchronous carcinomas or adenomas and local or distant metastases. In contrast, preoperative staging for rectal carcinoma has significant therapeutic implications and will direct the use of radiation therapy, surgical excision, or chemotherapy. CT of the chest, abdomen, and pelvis is recommended for the initial evaluation for the preoperative assessment of patients with colorectal carcinoma. Although the overall accuracy of CT varies directly with the stage of colorectal carcinoma, CT can accurately assess the presence of metastatic disease. MRI using endorectal coils can accurately assess the depth of bowel wall penetration of rectal carcinomas. Phased-array coils provide additional information about lymph node involvement. Adding diffusion-weighted imaging to conventional MRI yields better diagnostic accuracy than conventional MRI alone. Transrectal ultrasound can distinguish layers within the rectal wall and provides accurate assessment of the depth of tumor penetration and perirectal spread, and PET and PET/CT have been shown to alter therapy in almost one-third of patients with advanced primary rectal cancer. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Reviewing Imaging Examination Results With a Radiologist Immediately After Study Completion: Patient Preferences and Assessment of Feasibility in an Academic Department

OBJECTIVE The purpose of this study was to assess patient preferences about receiving radiology results and reviewing the images and findings directly with a radiologist after completion of an examination. SUBJECTS AND METHODS A prospective survey of English-speaking outpatients undergoing either nononcologic CT of the chest, abdomen, and pelvis or nonobstetric ultrasound examinations was completed between December 2010 and June 2011. Responses to survey items such as preferences regarding communication of results, knowledge of a radiologist, and anxiety level before and after radiologist-patient consultation were recorded. The average wait time between the end of the imaging examination and the consultation and the duration of consultation were documented. RESULTS Eighty-six patients (43 men, 43 women; mean age, 52 years) underwent 37 CT and 49 ultrasound examinations). Forty-eight patients (56%) identified a radiologist as a physician who interprets images. Before imaging, 70 patients (81%) preferred hearing results from both the ordering provider and the radiologist. This percentage increased to 78 (91%) after consultation (p=0.03). Before consultation, 84 of the 86 patients (98%) indicated they would be comfortable hearing normal results or abnormal results from the person interpreting the examination; the number increased to 85 (99%) after consultation. Eighty-five patients (99%) agreed or strongly agreed that reviewing their examination findings with a radiologist was helpful. Eighty-four patients (98%) indicated they wanted the option of reviewing or always wanted to review future examination findings with a radiologist. After consultation, anxiety decreased in 41 patients (48%), increased in 13 (15%), and was unchanged in 32 (37%) (p=0.0001). The average wait for consultation and the duration of consultation were 9.9 and 10.4 minutes for CT and 1.2 and 7.1 minutes for ultrasound. CONCLUSION Patients prefer hearing examination results from both their ordering provider and the interpreting radiologist. Most patients find radiologist consultation beneficial. Patients are comfortable hearing results from the radiologist, with most displaying decreased anxiety after consultation.

ACR appropriateness criteria right upper quadrant pain

Acute right upper quadrant pain is a common presenting symptom in patients with acute cholecystitis. When acute cholecystitis is suspected in patients with right upper quadrant pain, in most clinical scenarios, the initial imaging modality of choice is ultrasound. Although cholescintigraphy has been shown to have slightly higher sensitivity and specificity for diagnosis, ultrasound is preferred as the initial study for a variety of reasons, including greater availability, shorter examination time, lack of ionizing radiation, morphologic evaluation, confirmation of the presence or absence of gallstones, evaluation of bile ducts, and identification or exclusion of alternative diagnoses. CT or MRI may be helpful in equivocal cases and may identify complications of acute cholecystitis. When ultrasound findings are inconclusive, MRI is the preferred imaging test in pregnant patients who present with right upper quadrant pain. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Transhepatic Mechanical Thrombectomy Followed by Infusion of TPA into the Superior Mesenteric Artery to Treat Acute Mesenteric Vein Thrombosis

Abbreviations: SMA superior mesenteric artery, SMV superior mesenteric vein, TPA plasminogen activator ACUTE mesenteric vein thrombosis can be caused by a variety of factors including cirrhosis, neoplastic disease, intra-abdominal inflammatory diseases (most commonly pancreatitis), and hypercoagulable states (1). The clinical presentation can be varied and includes abdominal pain, nausea, vomiting, melena, or diarrhea (2). Recent advances in mechanical thrombectomy devices, such as the AngioJet catheter (3), have produced a new set of therapeutic options for treatment of vascular thrombosis. We present our experience using the AngioJet catheter to achieve rapid restoration of portal venous flow in a patient with acute thrombosis of the portal and superior mesenteric veins.

Reassessment of Vena Caval Filter Use in Patients with Cancer

PURPOSE Noting a doubling in mortality soon after placement of filters in the inferior vena cava (IVC) from 1985 (7.8%) to 1992 (15.2%), the authors performed a study to define risk factors associated with death soon after IVC filter placement and to develop revised guidelines for filter placement. PATIENTS AND METHODS During a 4-year period, 141 IVC filters were placed in 137 patients. Patients were divided into two clinical risk groups: those with possible malignancy and those with possible suprainguinal venous thrombus. Survival was monitored for up to 3 weeks after hospital discharge. RESULTS Death occurred in 16 (26%) of 61 patients with malignancy (P = .0086, compared with patients without malignancy), seven (35%) of 20 patients with suprainguinal venous thrombus (P = .0422, compared with patients without suprainguinal venous thrombus), and six (46.2%) of 13 patients with malignancy and suprainguinal venous thrombus (P = .0091, compared with patients without malignancy or suprainguinal venous thrombus). CONCLUSION The data indicate that for some patients with malignancy or suprainguinal venous thrombus, insertion of an IVC filter gives little or no survival benefit. A reassessment of IVC filter use in these patients is warranted.

Retrievable versus Permanent Caval Filter Procedures: When Are They Cost-effective for Interventional Radiology?

PURPOSE Because many retrievable inferior vena cava (IVC) filters are placed without ever being removed, placement of a retrievable device that is not removed incurs greater technical cost for the institution than a cheaper permanent filter (PF), with no clinical benefit for the patient and no additional professional or technical revenue for the interventional radiologist and institution. The purposes of this study are to identify patient characteristics associated with lack of removal of a retrievable filter (RF) and to develop a cost-effective strategy for placement of a retrievable IVC filter. MATERIALS AND METHODS A retrospective evaluation of 160 consecutive patients who underwent IVC filter placement with or without removal in our interventional radiology (IR) unit over a period of 31 months was performed. Patient characteristics were identified that were associated with lack of removal of retrievable IVC filters, and the cost savings were calculated in the event that a PF had been substituted for an RF in these patients. RESULTS A total of 160 consecutive IVC filters were placed during the study period. Of these, 42 (26%) were PFs and 118 (74%) were RFs. During the study period, only 27 of the 118 RFs (23%) were subsequently removed. Factors associated with lack of removal of an RF included patient age (P = .003), presence of ongoing malignancy (P = .04), and indication for filter placement (P = .01). Retrospectively, the use of retrievable devices only in the presence of two of the three selection criteria (ie, age <65 years, no ongoing malignancy, prophylactic indication) would have resulted in a net incremental benefit of

Outcome Analysis of Patients with Acute Pancreatitis by Using an Artificial Neural Network

59,562 for the IR service. CONCLUSIONS The preferential use of retrievable versus permanent devices for filter placement is financially advantageous for an IR unit only if at least 41% of them are eventually removed. The use of clinical criteria to select device type allows significant cost savings.

Utilization of Outpatient Diagnostic Imaging: Does the Physician’s Gender Play a Role?

RATIONALE AND OBJECTIVES The authors performed this study to evaluate the ability of an artificial neural network (ANN) that uses radiologic and laboratory data to predict the outcome in patients with acute pancreatitis. MATERIALS AND METHODS An ANN was constructed with data from 92 patients with acute pancreatitis who underwent computed tomography (CT). Input nodes included clinical, laboratory, and CT data. The ANN was trained and tested by using a round-robin technique, and the performance of the ANN was compared with that of linear discriminant analysis and Ranson and Balthazar grading systems by using receiver operating characteristic analysis. The length of hospital stay was used as an outcome measure. RESULTS Hospital stay ranged from 0 to 45 days, with a mean of 8.4 days. The hospital stay was shorter than the mean for 62 patients and longer than the mean for 30. The 23 input features were reduced by using stepwise linear discriminant analysis, and an ANN was developed with the six most statistically significant parameters (blood pressure, extent of inflammation, fluid aspiration, serum creatinine level, serum calcium level, and the presence of concurrent severe illness). With these features, the ANN successfully predicted whether the patient would exceed the mean length of stay (Az = 0.83 +/- 0.05). Although the Az performance of the ANN was statistically significantly better than that of the Ranson (Az = 0.68 +/- 0.06, P < .02) and Balthazar (Az = 0.62 +/- 0.06, P < .003) grades, it was not significantly better than that of linear discriminant analysis (Az = 0.82 +/- 0.05, P = .53). CONCLUSION An ANN may be useful for predicting outcome in patients with acute pancreatitis.